Suicidality among university students in the Eastern Mediterranean region: A systematic review

The prevalence of suicide attempts and suicidal ideation among university students is a global concern. Cultural values, social determinants, religion, and especially growing stress all play an important role in this. This systematic review aimed to identify potential protective and risk factors thought to be associated with suicidal ideation among students in the Eastern Mediterranean region and highlight the importance of developing an effective health care response. MEDLINE, CINAHL, Embase, PsycINFO, WHO Global Health Library, IMEMR, Web of Science Core Collections and Farsi and Arabic databases were searched for papers in English, Farsi, and Arabic. A combination of validated filters, free text keywords, and Mesh and Non-Mesh terms were used to retrieve relevant literature. A total of 2774 papers were found after the search, 257 selected for full-text review, and 72 papers included in the final review. Family and peer support play a potential protective role in the development of suicidal ideation among university students, while adverse life events, bullying, depression, anxiety, and other mental health conditions were identified as risk factors. Suicidality was likely under-reported due to stigma around social and cultural factors. Factors involving religion and culture may act as both protective and risk factors and require more in-depth investigation. The student population in the Eastern Mediterranean region face many challenges. The common theme of suicidality emerged as an indicator of an imbalance of resources and stress, which needs to be addressed proactively, given a most likely underreporting of suicidal ideation and attempts due to stigma.


Introduction
Suicide is a serious mental health issue and public health problem that claims the lives of 703,000 people every year, worldwide [1].It is estimated that for each suicide, there are between 10 to 30 attempts, and an exponentially greater number of individuals suffering from suicidal ideation [1].While suicide occurs across all ages, genders, and ethnicities, its rate is the inclusion and exclusion criteria.Any inconsistencies were reviewed by a third reviewer for inclusion or exclusion.Following the title and abstract screening, the full texts of the resulting studies were obtained and separately reviewed by two reviewers.Any discrepancies were resolved through a consensus discussion with all reviewers.A total of 72 studies were included in the review.
After screening, selecting, and evaluating the quality of selected studies, studies with missing data in their published reports were excluded, and data from the remaining studies were extracted in Microsoft Excel.Items for data extraction included information relevant to the publication (e.g., title, author, publication year), methods (e.g., type of the study, recruitment method, timeline, country, methodology of data collection and analysis), and the population of the study (e.g., sample size, age, gender, marital status, name of the school, place of residence, socioeconomic status).Population demographics, study methods, risk and protective factors of suicide were independently collected using the table.Risk and protective factors were defined as those that precede and are associated with a higher or lower likelihood of suicidality.Results were described both quantitatively and qualitatively to account for the high between-study heterogeneity observed, due to differences in instruments, environments, and mental health diagnoses.

Study quality assessment
The Newcastle-Ottawa Quality Assessment Scale for both cohort and cross-sectional studies were employed to assess quality and evaluate bias in all the articles included in the review.There were no randomised controlled trials, case-control studies, qualitative studies, or case reports found appropriate for analysis in this study.

Search results
The search in MEDLINE, CINAHL, Embase, PsycINFO, WHO Global Health Library, IMEMR, Web of Science Core Collections databases as well as 3 Farsi databases including Noormags, CIVILIKA, and SID, resulted in 2774 papers that were in English and French, 2333 after the removing the duplications, of which 257 were selected for full-text review and 72 were included in the study ( Fig 1).We were not able to access the full text version of any papers in Arabic as they were not available to the public.
Risk factors.The risk factors identified in this review include demographic and personal factors, mental health factors, and school-related factors.The demographic factors that increase the likelihood of suicidal ideation in Eastern Mediterranean students include being single [64,92], being part of the LGBTQI+ community [75], being widowed or otherwise separated from a partner [56], and residing in, or having connection to, high politicised regions [46].Living circumstances, specifically living alone, also increased the likelihood of having suicidal thoughts compared to students living with roommates [56].
Personal risk factors include adverse life events, negative family environments, and substance use.There is a non-linear association between negative life events and suicidal ideation [40].Factors including witnessing physical violence, familial mistreatment or neglect, and sexual abuse significantly enhance the risk for present suicidality, while parental separation and neglect significantly increase future risk for suicidal ideation [76].The feeling of helplessness within in the family, or perceived parental control has been observed to have significant, positive relationship with suicidal ideation [51].In one study of medical students, 10% reported that the decision to study medicine was imposed on them by family, resulting in their increased suicidality [42].Consumption of psychoactive substances, in particular illicit drugs, has also been associated with suicidal ideation [26,33].
Mental health symptoms are among the most consistently reported risk factors for suicide.Depression is consistently highly correlated with suicidal ideation in students [34,41,53,61,65,67,[70][71][72]77,86,94,95], to an extent that it has been observed to have the strongest predictive power over suicidality [72,77].Suicidal ideation was found to be increase by the severity of depression [74,75].Females with suicidal ideation were more likely to experience depressive symptoms than their male counterparts [49,53].Frequently, depression occurred with other mental health conditions, including but not limited to; anxiety, stress, panic, and

PLOS GLOBAL PUBLIC HEALTH
pessimism [21,24,38,53,70,71], which compounds the likelihood of suicidal ideation [38].Anxiety was also present in a large number of students with suicidal ideation [21,31,33,34,38,42,53,70,71,86].Similar to depression, females had a higher prevalence of anxiety than males [49,53].History of taking anxiety medication was also found to be significantly associated with suicidal ideation in students [79].Other symptoms including neuroticism, borderline and schizotypal personality disorders, perfectionism, and conditions affecting sleep quality, were also associated with enhanced suicidality in the Middle Eastern student population [42,56,87,89].Several school-related risk factors were associated with student suicide.While the majority of papers did not address the impact of bullying on suicidal ideation, those that did found that an overwhelming percentage of students had been bullied at least once throughout their lifetime [34], which significantly increased the likelihood of suicidal ideation [34,76].While both genders reported high rates of bullying, males had higher risk of suicide from school events in comparison to females [76].Feelings of anomie were observed to have a significant, positive correlation to suicidality [35,51,76].Females' suicide outcomes were affected more by feelings of anomie compared to males [76].There were considerable inconsistencies between studies investigating university programs and their correlation with suicidal ideation.Some papers posited that program choice may affect risk of suicidal ideation [70,76], whereas others argue that there is no significant relationship [63,71].Most studies agree that studying medical sciences are a particularly high-risk group [26,28,31,60,70].Level of education, specifically earlyyear and bachelor level, was also significantly correlated to suicidal ideation [26,63,70].Generally, heavy academic workloads, academic pressure, fear of failure, and lengthy courses all contributed to an increased risk of suicidal ideation in students [28,59].There is evidence that just being enrolled in university classes is associated with suicidal ideation [33].The societal pressure surrounding education and an expectation to perform, in some circumstances regardless of poor educational policies or less than ideal learning environments, is a major contributor to suicidality among students [34,42].
Protective factors.Interpersonal factors such as family and social support networks were identified as protective factors.Familial support is reported to be the primary source of support for students [26], seemingly acting as a mitigating factor against suicidal ideation [26,31,72].Perceived support from family has been observed to have an inverse relationship with the risk of suicidal ideation [26,27,31,67,72,83].Particularly, living with family members and effective parental communication were found to be especially protective [26,30,31,70].Outside of family members, multiple studies also observed a strong, negative correlation between suicidality and peer support [41,67,80].Only one study found no significant association between social support and suicidal ideation [37].
Both risk and protective factors.Sociocultural and religious factors were found to be both positively and negatively associated with suicide.Middle Eastern nations overwhelmingly favour traditional beliefs and conservative social values [34,49,94].This includes, but is not limited to, the stigmatisation of aberrant mental health and the strong condemnation of suicide, to the extent of prohibition in some localities [49,53].Consequentially, these social norms have directly contributed to both a lack of mental health professionals and an underutilisation of services that do exist, and high rates of psychological distress in the student population [34,60,94].While the stigmatisation of suicide has not been observed to be directly correlated with suicide in any of the studies, it has a number of indirect, negative impacts on Middle Eastern students, such as the avoidance of mental health services [34,53].Medical students in particular showed strong disapproval towards suicide from the belief in punishment in the afterlife post-suicide [30].One study has directly attributed suicidal stigma with a lower prevalence of suicidal thoughts reported in their sample population [49].This also raises issues concerning the accuracy of reporting, with the negative stigma potentially creating an inhibitory effect and skewing official suicide statistics [30,53].
Suicidal ideation was found to be negatively associated with religiosity [21,39,41,67,72,79,92].One study noted negative religious coping being significantly associated with suicide attempts, possibly due to the gradual loss of religious commitment when faced with adverse life experiences [39].However, there was no significant association between negative religious coping and suicidal ideation [39].Two studies also reported a negative association between religiosity and the acceptance of suicide [30,39].In some studies, positive religious coping and religion were considered protective factors against suicidal ideation [39,72].Students who expressed stronger religious beliefs were more likely to view suicide as an indicator of mental illness and demonstrated greater tendency and preparedness to support a suicidal friend [30].One study found no significant association between attitudes towards suicide and religiosity or the knowledge of the Islamic prohibition of suicide [39].Lastly, some studies indicated that suicidality might be under-reported in Eastern-Mediterranean countries due to religious restrictions [46] and suicide being considered a social taboo [34,60].

Study quality assessment
The 72 papers included in the review were all cross-sectional studies with a single exception.The lone paper was a cohort study and deemed of "good" methodological quality by the Newcastle-Ottawa Quality Assessment Scale, with a score of 8 of a possible 9, only losing a mark on the ability to compare cohorts based on the study design criteria.The overwhelming majority of the cross-sectional studies were rated as "good" methodological quality (a score of 6 or above up to 10).Eight papers were of "moderate" quality (with a score of 5) with flaws in their representativeness of the sample, affirming the exposure of the sample, or having an insufficient sample size.One paper was judged to be of "poor" methodological quality with a score of 3, with major issues regarding sample size, comparability, and assessment of the outcomes, amongst others (see S1 Table ).Lastly, 67 papers discussed suicidal ideation, 4 discussed suicide attempts, and 5 discussed both, and none of the papers focused on fatalities through suicide.

Discussion
To our knowledge, this is the first study to comprehensively explore and review literature around students' suicide in the Eastern Mediterranean region.Our goal was to provide a summary of the available studies around this population to guide and inform prevention and intervention practices.
Our review revealed that adverse life events, bullying, depression, anxiety, and other mental health conditions were identified as risk factors of suicidal ideation in university students, whereas family and peer support can play a protective role.Religion and cultural factors may act as both risk and protective factors.Sociocultural factors play a crucial role in developing a sense of belonging that protects individuals from feeling alienated and outcasted from the community.However, extreme emphasis on these norms and traditions may contrarily have a destructive effect on the mental well-being of people within the community.
The presented studies confirm that religious affiliation generally protects individuals against suicidal ideation, consistent with previous findings in which religiosity was shown to be significantly and negatively correlated with suicidal ideation [21].However, the prohibition of suicide by many religions such as Islam may indirectly perpetuate the stigma around suicide.More religious individuals are more likely to consider suicide an unforgivable sin, intertwining with stigmatizing attitudes towards suicide.As a result, those experiencing suicidal thoughts may refuse to seek help due to the fear of being stigmatized and perceived as sinful.
Moreover, the condemned view of suicide within religion may result in the under-reporting of suicide or attempting to disguise it, leading to inaccurate suicide statistics, and deflected attention from this concerning issue.
Students in the Eastern Mediterranean region are a high-risk population, not only due to their educational challenges, but from additional stressors specific to this region such as accessibility, national security concerns, social pressure, cultural restrictions, and potential lack of academic freedom.While all students require greater support, those under higher academic strain in the fields of humanities, sciences, or medicine may require focused interventions to reduce their perceived stress.
Furthermore, there is a substantial disparity between individuals needing care and those with access to mental health services within this region.The case is even worse for students due to the lack of awareness, support, and resources available to them.In a sample of Egyptian medical school students, Kamel et al. stated that only 6% of students with mental health problems could access professional assistance [25].This is likely to exacerbate mental health conditions for students, which are predisposing factors for the development of suicidal ideation and behaviour.
The unique sociocultural fabric of the Middle Eastern youth and adolescents must be considered in order to develop safe, accessible, and trust-worthy resources that address their barriers to service utilization.Due to their significant role in the decision making of youth, family and peer support should be highly integrated in the new system.The heavy use of internet within the population of university students and their familiarity with this technology could be leveraged to better guide youth through the mental healthcare system with web-based solutions dedicated to psychoeducation and counselling services that fit students' needs [20,23,96].As a good start, looking at the Egyptian experience, the ministry of health in collaboration with the WHO and experts from the university of British Columbia, has just launched a platform for E-Mental Health, as an innovative and appropriate alternative, considering the current inadequacy in the current youth mental health care system with high demand from youth to use this platform [36].
This study has some limitations.Firstly, the chosen countries for this study were based on the WHO list of Eastern Mediterranean countries which does not include all the countries commonly considered as the Middle East (e.g., Turkey and Algeria).Secondly, we were not able to access Arabic and Hebrew databases.Hence, papers written in these languages were not included.Thirdly, literature representing some Eastern Mediterranean countries is scarce.Therefore, some countries and their populations were not represented (e.g., Afghanistan), whereas other countries were overrepresented (e.g., Iran).Additionally, Israel and Palestine share a geographical region, but Palestine is considered an Eastern Mediterranean country, whereas Israel is not.This makes it difficult to know whether a study's population from this region is limited to the Eastern Mediterranean.Most studies were also carried out with medical or paramedical students, who are generally perceived as being under high academic stress.Future studies could explore the interrelatedness of suicidal ideation with medical studies among other studies of similar and dissimilar rigor, as well as identify specific interventions that could better understand and promote students' well-being and coping in medical school.Lastly, the vast majority of studies did not control for receiving treatment for suicidal ideation, with some going to the extent of excluding participants who gained access to medication or psychotherapy [93].Not controlling for receiving treatment could be due to the extremely limited number of students who received actual treatment for suicidal ideation, either caused by a lack mental health resources or even a lack of awareness of psychological disorders among the Middle Eastern population.

Conclusions
Risk for suicidality among students in the eastern Mediterranean is related to demographics, individual factors, mental health, and school-related stress and bullying.Peers and family support has potential to protect students from developing suicidal ideation.Religion and cultural values play an important role in stigma and underreporting the extent of suicide in this population.The awareness of these high prevalence of suicidality among youth is low and no specific preventative measures or treatment options are reported.